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People with learning disabilities still face inequalities in access to health services. This article, which comes with a handout for a journal club discussion, sums up what nurses can do to reduce these inequalities

Does plain packaging help smokers quit?

Plain cigarette packs “encourage smokers to quit” is the BBC News headline, while The Daily Telegraph reports there is “no excuse for delay on plain cigarette packaging”.

They report on the results of a survey comparing the smoking beliefs and thoughts about quitting of people who smoked using plain cigarette packs compared to those that smoked using branded packs during the time plain packs were introduced by law in Australia. Since the end of 2012, all tobacco products have been sold in generic brown packs with no branding, but with prominent and graphic images designed to prompt people to quit smoking.

The researchers found that, compared to smokers of branded cigarette packs, smokers who smoked from plain cigarette packs with large front-of-pack health warnings, were more likely to:

perceive their tobacco to be of lower quality and less satisfying than a year ago

think about and prioritise quitting

support the plain packaging law

However, people were surveyed at only one point in time. It is currently not clear whether the changes in attitudes would lead to people quitting. The survey only looked at adults’ beliefs, so we can’t say if younger people would have the same reactions.

This is a useful piece of research carried out with a relatively large and representative sample. It has added to the debate about whether similar packaging laws should be introduced in England.

Where did the story come from?

The study was carried out by researchers from the Centre for Behavioural Research in Cancer at Cancer Council Victoria in Australia and was funded by the anti-tobacco lobbying organisation Quit Victoria.

From September 2012, all tobacco manufactured for sale in Australia was required to be manufactured in plain dark brown packs, with health warnings that took up the majority of space on the front of the pack. The brand name has been limited to standardised font and size and provided on the front of the pack.

These new plain packs began appearing in retail outlets in October 2012 and by 1 December 2012, all tobacco sold at retail was required by law to be contained in plain packs. The roll-out of the new plain packs was accompanied by a national mass media campaign.

The research authors say plain tobacco packaging aims to reduce the attractiveness and appeal of tobacco, increase the noticeability and effectiveness of health warnings, and to reduce the ability of branded packs to mislead the general public about smoking harms.

It is also hoped that the use of plain packaging will discourage children from taken up the habit.

Australia is the first country to implement plain packaging, so all studies up until now have ‘simulated’ plain packaging rather than studying a real-life situation.

The UK media’s reporting of the study was broadly accurate. As you would expect, many of the newspapers mentioned the recent decision of the Government not to pass packaging laws due to there currently being “not enough evidence to prove plain packaging works”.

What kind of research was this?

those who smoked from plain tobacco packs with large front-of-pack health warnings, who were compared to

those who smoked from branded packs with smaller health warnings

This type of study looks at the characteristics of a population at a given point in time, in this instance, the attitudes and intentions of the population about smoking tobacco. Because this study looks only at one point in time, it cannot establish cause and effect between factors, or say that the packaging is the cause of the change in attitudes.

Importantly, it cannot tell us whether a change in packaging achieves the desired outcomes of an increase in actual quit rates or preventing people from starting smoking.

What did the research involve?

The researchers looked at data collected through a wider annual population survey of adults in Victoria state. The 12-minute survey was conducted in November and December 2012 (during the roll-out phase of the introduction of plain tobacco packaging) and is reported as being representative of adults aged 18 years and older in Victoria.

The survey methods used random digit dialling to landlines or mobile phones to reach participants. Letters were sent to landlines that had linked residential addresses to notify people of the survey. When calling landlines, interviewers asked to speak to the youngest male aged 18 years or older at home at the time of the call. If no men were available, the youngest adult woman was selected to participate. When interviewers called mobile phones, the person answering was considered the selected participant.

To complete interviews, up to nine call attempts were made to landlines and up to four attempts were made to mobile phones. Interviews were only conducted in English.

Smokers were identified as people who currently smoked cigarettes, pipes and or cigars:

daily

weekly

less than weekly

Participants were then asked about the type of tobacco they smoked. They were considered current cigarette smokers if they smoked factory-made cigarettes or “roll-your-own” cigarettes (roll-ups) daily, weekly or less than weekly.

All cigarette smokers were asked to specify their usual cigarette brand and brands were categorised as value, mainstream or premium based on price definitions from a trade magazine.

To determine exposure to the new plain packs, cigarette smokers were asked, “is the cigarette tobacco pack you are currently smoking one of the new dark brown packs which has all of its logos removed and a large picture health warning on the front?”

The researchers’ primary outcomes of interest were:

how smokers perceived quality and satisfaction of cigarettes compared with a year ago

how often smokers thought about how harmful smoking is

smokers’ perceived exaggeration of harms

how often smokers thought about quitting

what “life priority” smokers put on quitting

smokers’ intention to quit

smokers’ approval of large graphic health warnings and plain packaging

Interviewers asked questions about these outcomes and participants were asked to select answers from different Likert scales that varied from strongly disagree to strongly agree and on scales of 1 to 10. Self-reported consumption of cigarettes was used to calculate the average number of cigarettes smoked per day and participants were categorised into three socioeconomic groups based on postal area.

The researchers compared the results of smokers who reported smoking from plain tobacco packs compared to those who smoked from branded packs using statistical methods. Results were adjusted for:

socioeconomic status

daily consumption level

recalling of at least one anti-smoking advertisement

brand segment (value, mainstream or premium)

previous quit attempt

All data were weighted by age and sex based on a previous national census.

What were the basic results?

Of 4,005 interviews that took place, 536 current cigarette smokers who smoked a usual brand were included in the analysis. Of these, 72% (388 people) smoked from a plain pack and 28% (148 people) smoked from a branded pack.

Following adjustments, the main findings of the study were that, compared with people smoking from branded packs, people smoking from plain packs were significantly more likely to:

perceive their cigarettes to be lower in quality compared to a year ago

perceive their cigarettes as less satisfying than a year ago

have thought about quitting at least once a day in the past week

have rated quitting as a higher priority in their lives

support the plain packaging policy

There was no significant difference between groups for intentions to quit smoking, frequency of thoughts about harms or perceived exaggeration of harms.

How did the researchers interpret the results?

The researchers conclude that early findings indicate plain packaging is associated with lower smoking appeal, more support for the policy and more urgency to quit among adult smokers.

They say: “Overall, the introductory effects we observed are consistent with the broad objectives of the plain packaging legislation.” They await further research into the effects of plain packaging on younger smokers.

Conclusion

This was a useful piece of research that informs how attitudes and beliefs to smoking may be influenced by a change in packaging.

The study’s strengths are that it is based on a relatively large representative sample of people from one Australian state, and that it was timed to occur during the introduction of plain tobacco packaging in Australia.

However, there are important limitations to the conclusions that can be drawn from this research, including:

that people were surveyed at only one point in time and attitudes may have changed if surveyed at a different period of time

that the study could not assess whether a change in packaging achieves the desired outcomes – of an increase in quit rates

whether the change in packaging prevented people from starting smoking in the first place

While people smoking the plain pack cigarettes were significantly more likely to have thought about quitting and place higher priority on quitting, their intention to quit smoking remained unchanged.

Because the interviews were carried out in English, the findings may not apply to other populations (as it is known that reactions to branding can be culture-specific). It also only looked at adult’s beliefs, so the findings cannot be generalised to younger people.

The authors also report that the study was not designed to analyse the individual effects of both the plain packaging and the new larger graphic-health warning, because they were introduced at the same time.

It’s also worth noting that the amount people smoked was based on their own reporting, and there is a possibility that participants did not report their level of smoking consumption accurately. This could potentially bias the results as could the fact that some of the smokers of branded packs, may have previously smoked from plain packs.

Nevertheless, despite limitations, this study has potential implications for public health and provides early findings of attitudes and intentions of smokers about plain tobacco packaging.

As Australia is currently serving as the only test bed (though other countries are considering introducing similar laws), further research on the effects of plain tobacco packaging will be studied with interest.

The new 10-year plan for the health service in England was published on 7 January, after being delayed since the end of last year. The 136-page blueprint sets out how a £20.5bn annual budget increase will be spent.

The much-anticipated plan for the long-term future of the NHS will be published tomorrow, the government has confirmed, but commentators have already criticised an expected delay to the part relating to workforce issues.

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